Search Results (178)

Transesophageal echocardiography (TEE) has emerged as the pivotal imaging modality in transcatheter mitral valve replacement (TMVR), bridging the gap between anatomical complexity and procedural precision. Unlike any other tool, TEE accompanies the patient journey across all stages of TMVR, from patient assessment and device selection to intraprocedural guidance and post-implant surveillance, providing real-time insights into valve anatomy, hemodynamics, and complications. This review consolidates the most recent consensus statements, quantitative thresholds, and device-specific considerations, while also highlighting evolving technologies. By outlining best practices for integrating TEE within multimodality workflows and the Heart Team paradigm, this article offers clinicians a comprehensive and practice-oriented roadmap for optimizing TMVR outcomes. Full article

Background/Objectives: Acute bacterial endocarditis (ABE) is a frequent situation and continues to be a challenge. Mitral valve involvement during acute bacterial endocarditis is often the result of the spread of the endocarditic process from the adjacent aortic valve. Mitral involvement, on the other hand, could also be an expression of the initial localization of the bacteria. The best option for treating mitral ABE is still a matter of debate. Recent reports have shown satisfactory results with mitral reconstructive techniques in the treatment of mitral ABE. In this study, we present a comprehensive review of our 10-year institutional experience in the surgical management of acute mitral endocarditis with a focus on technical considerations, outcomes, and the durability of mitral valve repair in this high-risk population. Methods: We queried the institutional database, cross-referencing patients admitted with a diagnosis of “acute bacterial endocarditis” with patients undergoing surgical procedures for “valvular disease” at our division. Out of 1136 valvular procedures listed in our PACS database, 180 patients were admitted with a diagnosis of active acute endocarditis, and 46 included treatment of the mitral valve. We analyzed and compared short- and long-term follow-up (ranging from 3 to 141 months with a mean of 42 ± 38 months) of these 46 patients, dividing them into two groups: mitral valve repair (MVr) and mitral valve replacement (MVR). Results: 18 (40%) patients underwent reconstructive treatment of the mitral valve, and 28 (60%) underwent mitral valve replacement. Cumulative in-hospital mortality was 10% (5 pts, all from the MVR group), however, with no difference between the two groups. A shorter time gap from diagnosis to surgery (<10 days) was the only predictive factor for early mortality. A further 11 patients died during follow-up (2 from group A and 9 from group B). Long-term survival, on the other hand, was negatively influenced by MV surgical replacement (p = 0.0178), older patients’ age (>60 years), and urgent surgical procedures. Finally, patients with MVr also experienced a favorable postoperative event-free curve for endocarditis recurrence (p = 0.0260) and time elapsed before recurrence (p = 0.0438). Conclusions: Mitral valve repair in the case of active endocarditis could be a treatment associated with more favorable outcomes, providing that a complete eradication of infective tissue can be accomplished. Conservative treatment, when feasible, seems to offer favorable cumulative long-term outcomes. Full article

Background: Pulmonary hypertension is common in left-sided heart valve disease, with historical studies reporting mortality rates up to 31% in severe cases undergoing mitral valve surgery. This study evaluates the impact of severe pulmonary hypertension on outcomes of mechanical mitral valve replacement with posterior leaflet preservation by comparing results with patients having mild-to-moderate pulmonary hypertension. Methods: Prospective analysis of 86 patients with mitral valve disease undergoing mechanical valve replacement with posterior leaflet preservation from March 2015 to September 2016 was conducted. Patients were stratified by pulmonary artery pressure: severe (≥60 mmHg, n = 19) versus mild–moderate (35–59 mmHg, n = 67). Primary outcomes included mortality, complications, and functional recovery at 1, 6, and 12 months. Results: The cohort included 67 patients (77.9%) with mild–moderate pulmonary hypertension and 19 patients (22.1%) with severe pulmonary hypertension. Severe pulmonary hypertension patients demonstrated higher NYHA functional class (73.7% class III vs. 46.2%, p = 0.03), larger left atrial diameter (56.3 ± 9.8 vs. 49.5 ± 6.7 mm, p = 0.01), and higher mean pressure gradients (14.4 ± 5.3 vs. 11.3 ± 5.0 mmHg, p = 0.025). Mortality was 5.3% in the severe group versus 0% in the mild–moderate group (p = 0.331). Patients with severe pulmonary hypertension required longer ICU stays (6.3 ± 3.7 vs. 4.7 ± 2.2 days, p = 0.024) but showed no significant differences in ventilation time, reoperation rates, or major complications. At the 12-month follow-up, both groups achieved equivalent outcomes in pulmonary artery pressures, left ventricular function, and cardiac dimensions. Conclusion: In this study with a relatively small sample size, severe pulmonary hypertension was associated with significantly longer intensive care unit stay but not with higher mortality compared to mild–moderate pulmonary hypertension, with both groups attaining comparable functional and hemodynamic parameters at 12 months after mechanical mitral valve replacement with posterior leaflet preservation. Full article

Background/Objectives: Despite growing awareness of mitral annular disjunction’s (MAD) clinical significance, robust data regarding the outcomes of surgical interventions on MAD remain sparse. This meta-analysis aims to systematically evaluate the current evidence on the efficacy and safety of mitral valve (MV) surgery in patients with MAD. Methods: A systematic review was conducted from inception until May 2025 for studies comparing patients undergoing MV surgery with and without MAD and was registered in PROSPERO: CRD42025649821. Results: Patients with MAD were generally younger (59.3 ± 5.0 vs. 63.4 ± 2.2 years, standardized mean difference: −0.3073), had fewer comorbidities but more complex valve lesions (41.0% vs. 13.7%, risk difference: 0.2627) compared to those without MAD. MV replacement was performed less frequently in the MAD group than in the No-MAD group (risk ratio, RR: 0.690 [95% confidence interval, CI: 0.508; 0.937], p = 0.017), probably related to the significant difference in age between the two groups. The MAD cohort demonstrated a higher incidence of ventricular arrhythmia both after surgery (RR: 7.255 [95%CI: 1.231; 42.763], p = 0.029) and during follow-up (incidence rate ratio, IRR: 2.750 [95%CI: 1.372; 5.512], p = 0.004). Although the MAD group experienced more arrhythmic events over time, this did not translate into a significant difference in overall mortality compared to patients without MAD (IRR: 0.573 [95%CI: 0.072; 4.555], p = 0.599). Conclusions: This meta-analysis revealed significant baseline differences between the populations. Our findings suggest that patients with MAD remained at significantly higher risk for both postoperative and long-term arrhythmias. These results highlight the need for close arrhythmic surveillance in this population. Full article

Background: Valvular heart disease remains a major global health issue, with mechanical prosthetic heart valves (MPHVs) widely used in surgical valve replacement. However, these devices carry a risk of thrombosis, particularly in the mitral position. Several mechanisms may be involved in this risk, but the role of oxidative stress (OxS) remains unclear. Our aim was to assess the relationship between OxS impairment and platelet activation. Methods: We analyzed data from a pilot, observational, monocentric study conducted at our anticoagulation clinic at Sapienza University of Rome, involving adult patients with MPHVs (aortic or mitral) on vitamin K antagonist therapy, enrolled between June and September 2024. Clinical data and blood samples were collected to evaluate markers of NOX2-mediated OxS (sNOX2-dp, H₂O₂) and platelet activation (sCD40L) using ELISA-based assays. Results: Our cohort included 30 patients with mitral MPHVs and 30 patients with aortic MPHVs (46.7% males, 53.3% females). Serum sNOX2-dp and H₂O₂ were significantly higher in patients with mitral MPHVs (28.69 [25.08–33.18] vs. 24.27 [17.30–26.41] pg/mL, p = 0.001, and 22.94 [15.79–27.33] vs. 16.73 [12.50–20.87] µM, p = 0.013, respectively) compared with aortic MPHV patients. sCD40L was significantly elevated in mitral versus aortic MPHVs (5.61 [3.69–6.89] vs. 3.65 [2.14–5.54] ng/mL, p = 0.009). Spearman’s correlation analysis showed a significant correlation between sNOX2-dp levels and sCD40L in both groups (mitral MPHVs: r_s = 0.521, p = 0.003; aortic MPHVs: r_s = 0.443, p = 0.014). Conclusions: Mitral MPHVs are associated with heightened OxS and platelet activation compared to aortic MPHVs. These findings may help explain the higher thrombotic risk observed with mitral valves and support differential management strategies. Full article

Background and Clinical Significance: Left atrial dissection is a rare surgical complication (occurring in 0.16% of cases), which results in the formation of a large cavity between the endocardium and the epicardium. Case Presentation: We report a case of a 78-year-old man who underwent combined aortic and mitral valve replacement. Extensive debridement of the calcified mitral annulus most probably precipitated the formation of a dissection flap detected by transesophageal echocardiography after protamine administration. Profound hypotension and hemodynamic instability were treated with inotropic and vasopressor support and fluid administration without any further surgical intervention. Conclusions: The patient recovered uneventfully under conservative management, highlighting the importance of perioperative echocardiography for prompt diagnosis and tailored intervention. Full article

Background/Objectives: The objective of this study was to characterize echocardiographic characteristics comparing patients accepted or deemed unsuitable for transcatheter mitral valve interventions. Methods: We performed a retrospective analysis of 293 patients with severe mitral regurgitation evaluated for mitral transcatheter edge-to-edge repair (M-TEER) or transcatheter mitral valve replacement (TMVR), if patients were primarily identified as unsuitable candidates for M-TEER, at our institution between 2018 and 2023. All patients underwent transthoracic and transesophageal echocardiography, and mitral valve quantification (MVQ) analysis was performed. Feasibility was determined by an interdisciplinary Heart Team based on quantitative data and semi-quantitative echocardiographic parameters, including mean pressure gradient, regurgitation volumes, and morphological aspects alongside clinical assessment. Patient characteristics were evaluated using clinical records and echocardiographic data. Results: We screened 195 patients for M-TEER, 168 of which were accepted for the procedure. M-TEER-rejected patients presented with higher regurgitation volumes and higher transmitral pressure gradients than those accepted to undergo M-TEER. We then screened 104 patients for TMVR, and 27 were approved for the procedure. Patients rejected for TMVR presented with lower tenting volume, area, and height and had smaller ventricular diameters. Further, mitral valve area appears to be an important parameter in determining MR treatment strategy. Conclusions: The majority of MR patients screened for transcatheter intervention were suitable for M-TEER. However, elevated MPG and more pronounced billowing were the main factors associated with M-TEER exclusion. Conversely, the only morphological parameter associated with TMVR refusal was small left ventricular size. Importantly, the multimorbidity of patients and level of critical illness did not prohibit TMVR. Full article

Background: Mitral valve replacement presents considerable challenges in the field of cardiothoracic surgery, particularly in patients aged 50 to 69, where the decision between bioprosthetic and mechanical valves is critical. Nevertheless, the optimal selection of prosthetic valves for candidates within this age-related gray zone remains inadequately defined, necessitating a thorough evaluation of long-term outcomes and associated risks. Objective: This study aims to assess mid-term outcomes of MIMVR in patients aged 50 to 69, comparing reoperation rates, prosthesis-related morbidity, and overall survival between bioprosthetic and mechanical valves. While many prior studies on valve choice in patients aged 50 to 69 years are derived from sternotomy cohorts, the novelty of our work lies in the exclusive focus on patients undergoing minimally invasive techniques. Methods: A retrospective analysis was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, including 172 patients aged 50–69 years who underwent minimally invasive mitral valve replacement via right minithoracotomy at a high-volume center in Germany between 2011 and 2023. Of the 172 patients, 95 underwent MIMVR using biological prostheses, while 77 received mechanical prostheses. Comprehensive data on demographics, surgical procedures, and postoperative complications, as well as long-term outcomes, were analyzed. Results: With a mean follow-up of 7.1 years, early outcomes revealed no significant differences in 30-day mortality (7.4% for bioprosthetic vs. 2.6% for mechanical; p = 0.06). There was no significant differences in all-cause mortality at 1 year (8.4% vs. 3.9%; p = 0.22), 3-year (9.5% vs. 7.8%; p = 0.69), and 5-year (13.7% vs. 10.4%; p = 0.19), or at the longest follow-up (13.7% vs. 10.4%; p = 0.51). Kaplan–Meier analysis showed no significant difference in long-term survival between the groups (p = 0.5427). Postoperative arrhythmia occurred significantly more frequently in the biologic group compared to the mechanical group (18.9% vs. 6.5%; p = 0.01). Conclusions: For patients aged 50–69 undergoing MIMVR using a bioprosthetic or mechanical valve, the mid-term survival and incidence of reoperation and re-hospitalization were comparable up to 7 years. This provides evidence supporting the safe application of the MICS approach with either valve type in this gray-zone age group. Full article

Background and Objectives: Prosthetic valve thrombosis (PVT) represents a rare but critical complication after heart valve replacement surgery. This study aimed to evaluate patient characteristics, treatment modalities (medical vs. surgical), and clinical outcomes in patients with PVT over a 15-year period, with a particular focus on the impact of New York Heart Association (NYHA) functional class on mortality. Materials and Methods: We retrospectively analyzed 76 patients with confirmed PVT (54 mitral, 20 aortic, and 2 tricuspid; 97.4% mechanical) treated at a single tertiary center between 2005 and2020. The treatment comprised intravenous unfractionated heparin (UFH) alone (n = 29), low-dose tissue plasminogen activator (t-PA) (n = 27), or surgical re-operation (n = 20). Primary endpoints were treatment success, in-hospital mortality, and complications. Results: Overall, the treatment success was 60.5% (46/76) with a 25.0% (19/76) in-hospital mortality. UFH therapy achieved a 67.6% success with a 24.3% mortality. Low-dose t-PA demonstrated a 59.3% success with a significantly lower mortality (7.4%, p = 0.004). The surgery showed a 50% success with a 50% mortality. Patients in the NYHA class III-IV had markedly higher mortality (68.2% vs. 11.1%, p < 0.001) and lower treatment success (27.3% vs. 81.5%, p < 0.001) compared to the NYHA class I-II. A multivariate analysis revealed NYHA III–IV as the strongest predictor of mortality (OR 12.639, 95% CI: 1.905–83.849, p = 0.009). Conclusions: The low-dose t-PA (25 mg total dose) therapy showed the lowest mortality among treatment modalities. The NYHA functional class emerged as the most significant predictor of outcomes, with the class III-IV patients having >12-fold increased mortality risk. These findings support early intervention and suggest that t-PA is a viable first-line option in selected patients. Full article

Background: The guidelines recommend mitral valve repair whenever possible in patients undergoing surgical treatment for active infective endocarditis of the native mitral valve. However, the impact of causative microorganisms in relation to treatment strategies, especially Staphylococcus aureus, has not been studied. In this study, we aimed to compare the outcomes of mitral valve repair versus replacement in patients with native mitral valve infective endocarditis caused by methicillin-susceptible Staphylococcus aureus. Methods: Consecutive patients with definitive active infective endocarditis of the native mitral valve caused by methicillin-susceptible Staphylococcus aureus undergoing cardiac surgery between 2012 and 2022 were selected. Patients were classified according to the treatment received in two groups: repair and replacement. Inverse propensity treatment weighting was employed to correct for confounders. The endpoints were all-cause mortality, incidence of recurrent endocarditis, reoperation rate, and event-free survival at two-year follow-up. Results: Among 170 operated-upon patients with active infective endocarditis of the native mitral valve, 44 cases were caused by methicillin-susceptible Staphylococcus aureus. A total of 23 patients underwent mitral valve repair and 21 patients received mitral valve replacement. Weighted 30-day mortality in the repair group was 43%, versus 27% in the replacement group (p = 0.15). Two-year mortality increased to 57% in the repair group and 32% in the replacement group (p = 0.02). Three patients developed recurrent endocarditis in the repair group, while no recurrent endocarditis occurred in the replacement group. Three patients in the repair group required reoperation due to recurrence and one patient in the replacement group underwent re-operation due to paravalvular leakage. Weighted two-year event-free survival was 29% in the repair group and 59% in the replacement group (p < 0.01). Conclusions: Mortality in patients with mitral valve infective endocarditis caused by Staphylococcus aureus is extremely high, especially in patients undergoing mitral valve repair. The risk of recurrent endocarditis and mid-term mortality seems to be higher in mitral valve repair, resulting in poor event-free survival during two-year follow-up. However, the sample size was likely insufficient for drawing definitive conclusions. Full article

Background: Right anterior mini-thoracotomy has gained increasing popularity as a preferred approach for mitral valve surgery due to its numerous advantages. This study aims to evaluate the safety and efficacy of this technique in elderly patients. Methods: Between January 2010 and November 2024, a total of 4092 adult patients underwent mitral valve repair or replacement at our institution. Of these, 1687 patients were treated using a minimally invasive approach. This analysis focuses on elderly patients aged 75 years and older (n = 402), further subdivided into two groups: 75–79 years (n = 253) and 80 years and older (n = 149). Results: The study population comprised 49.8% male patients. A small percentage (1.7%) had a history of endocarditis, and 6.5% had undergone prior cardiac surgery. The median logistic EuroSCORE was 7.68 (IQR 5.83–11.00), and the median EuroSCORE II was 2.75 (1.71, 4.40). Alternative cannulation strategies, guided by AngioCT scans, can expand the applicability of this technique to patients unsuitable for femoral cannulation. Median durations for cardiopulmonary bypass (CPB) and aortic cross-clamping were 99.5 and 80.0 min, respectively. Median ventilation time was 7 h, and the median ICU stay was 2 days. Atrial fibrillation was the most common postoperative complication (20.9%). A significant proportion of patients (47.8%) required blood transfusions, and 3.0% needed re-exploration for bleeding. The in-hospital mortality rate was 3.7%, with 7 (1.7%) patients requiring postoperative dialysis and 5 (1.2%) experiencing sepsis and multiple organ failure. Patients aged 80 years and older exhibited worse renal function and higher EuroSCOREs compared to the younger group (p < 0.001). However, they had shorter CPB (p = 0.004) and cross-clamp times (p = 0.001) and underwent a higher proportion of valve replacements (p = 0.003). Rates of major complications and in-hospital mortality were comparable between the two age groups. Logistic regression analysis identified the logistic EuroSCORE as the only significant preoperative risk factor (p = 0.001). Conclusions: Right anterior minithoracotomy is a safe and reproducible surgical approach, even in elderly patients, promoting faster recovery with a lower risk of complications. Among patients aged >80 years, despite higher comorbidities and elevated EuroSCORE II, in-hospital outcomes are comparable to those aged 75–79 years. Full article

Background and Objectives: Despite significant advances in surgical techniques and perioperative care, major adverse cardiovascular events (MACE) remain a leading cause of postoperative morbidity and mortality in patients undergoing coronary artery bypass grafting and/or aortic valve replacement. Accurate preoperative risk stratification is essential yet often limited by models that overlook atrial mechanics and underutilized biomarkers. Materials and Methods: This study aimed to develop an interpretable machine learning model for predicting perioperative MACE by integrating clinical, biochemical, and echocardiographic features, with a particular focus on novel physiological markers. A retrospective cohort of 131 patients was analyzed. An Extreme Gradient Boosting (XGBoost) classifier was trained on a comprehensive feature set, and SHapley Additive exPlanations (SHAPs) were used to quantify each variable’s contribution to model predictions. Results: In a stratified 80:20 train–test split, the model initially achieved an AUC of 1.00. Acknowledging the potential for overfitting in small datasets, additional validation was performed using 10 independent random splits and 5-fold cross-validation. These analyses yielded an average AUC of 0.846 ± 0.092 and an F1-score of 0.807 ± 0.096, supporting the model’s stability and generalizability. The most influential predictors included total atrial conduction time, mitral and tricuspid annular orifice areas, and high-density lipoprotein (HDL) cholesterol. These variables, spanning electrophysiological, structural, and metabolic domains, significantly enhanced discriminative performance, even in patients with preserved left ventricular function. The model’s transparency provides clinically intuitive insights into individual risk profiles, emphasizing the significance of non-traditional parameters in perioperative assessments. Conclusions: This study demonstrates the feasibility and potential clinical value of combining advanced echocardiographic, biochemical, and machine learning tools for individualized cardiovascular risk prediction. While promising, these findings require prospective validation in larger, multicenter cohorts before being integrated into routine clinical decision-making. Full article

Background: Coronary heart disease (CHD) remains the most prevalent pathology within the circulatory system. Among its chronic complications, ischemic mitral valve regurgitation (IMR) is observed in approximately 15% of patients with sustained myocardial ischemia. The presence of this complex valvular defect significantly increases both overall mortality and the incidence of adverse cardiovascular events. Notably, the presence of moderate to severe mitral regurgitation in patients undergoing surgical revascularization has been shown to double the risk of death. Despite the well-established etiology of IMR, data regarding the efficacy of surgical interventions and the determinants of postoperative outcomes remain inconclusive. Methods: The objective of the present study was to evaluate both early and long-term outcomes of surgical treatment of mitral regurgitation in patients undergoing coronary artery bypass grafting (CABG) due to ischemic heart disease. Particular attention was given to the influence of the severity of regurgitation, left ventricular ejection fraction (LVEF), and the dimensions of the left atrium (LA) and left ventricle (LV) on the postoperative prognosis. An additional aim was to identify preoperative risk factors associated with increased postoperative mortality and morbidity. A retrospective analysis was conducted on 421 patients diagnosed with ischemic mitral regurgitation who underwent concomitant mitral valve surgery and CABG. Exclusion criteria included emergent and urgent procedures as well as non-ischemic etiologies of mitral valve dysfunction. Results: The study cohort comprised 34.9% women and 65.1% men, with the mean age of 65.7 years (±7.57). A substantial proportion (76.7%) of patients were aged over 60 years. More than half (51.5%) presented with severe heart failure symptoms, classified as NYHA class III or IV, while over 70% were categorized as CCS class II or III. Among the surgical procedures performed, 344 patients underwent mitral valve repair, and 77 patients required mitral valve replacement. Additionally, 119 individuals underwent concomitant tricuspid valve repair. Short-term survival was significantly affected by the presence of hypertension, prior cerebrovascular events, and chronic kidney disease. In contrast, hypertension and chronic obstructive pulmonary disease were identified as significant predictors of adverse late-term outcomes. Conclusions: Interestingly, neither the preoperative severity of mitral regurgitation nor the echocardiographic measurements of LA and LV dimensions were found to significantly influence surgical outcomes. The perioperative risk, as assessed by the EuroSCORE II (average score: 10.0%), corresponded closely with observed mortality rates following mitral valve repair (9.9%) and replacement (10.4%). Notably, the need for concomitant tricuspid valve surgery was associated with an elevated mortality rate (12.4%). Furthermore, the preoperative echocardiographic evaluation of LA regurgitation severity, as well as LA and LV dimensions, did not exhibit a statistically significant impact on either early or long-term surgical outcomes. However, a reduced LVEF was correlated with increased long-term mortality. The presence of advanced clinical symptoms and the necessity for tricuspid valve repair were independently associated with a poorer late-term prognosis. Importantly, the annual mortality rate observed in the late-term follow-up of patients who underwent surgical treatment of ischemic mitral regurgitation was lower than rates reported in the literature for patients managed conservatively. The EuroSCORE II scale proved to be a reliable and precise tool in predicting surgical risk and outcomes in this patient population. Full article

Background: The development of transcatheter mitral valves (TMVs) represents a major advancement in cardiology, driven in part by the growing elderly population. Elderly patients frequently suffer from secondary mitral regurgitation but are often ineligible for surgical valve replacement due to high procedural risks. This study aimed to develop a self-expanding TMV stent fabricated from a single nitinol tube, featuring two distinct central zones: a smaller-diameter valve-containing segment and a larger-diameter anchoring segment for the mitral annulus. Methods: We used the COMSOL Multiphysics 6.0 software package for biotechnical engineering. Prototypes of stents and valves were manufactured in five sizes following a 22 Fr delivery system compatibility assessment and pulsatile-flow testing. Results: We bioengineered a novel stent design with an integrated porcine pericardial valve. The stents were laser-cut from nitinol tubes (4.5 mm outer diameter, 0.45 mm wall thickness) and heat-treated to achieve spatial configurations compatible with fibrous ring diameters of 40, 42, 44, 46, and 48 mm. Pericardial leaflets and coverings were then mounted onto the stents. The resulting valves were successfully loaded into a 24 Fr delivery system and exhibited proper opening and closing function under pulsatile-flow testing. Conclusions: Our findings confirm the feasibility of a single-component, dual-diameter TMV stent, offering a promising solution for high-risk patients with mitral regurgitation. Full article

Mitral valve disease, particularly in the context of extensive mitral annular calcification (MAC), poses significant challenges for traditional surgical management. Transcatheter mitral valve replacement (TMVR) has emerged as a promising alternative for high-risk and inoperable patients, driven by rapid advancements in valve technology, imaging techniques, and procedural strategies. Nevertheless, complications such as paravalvular leak (PVL), left ventricular outflow tract (LVOT) obstruction, and hemolysis remain obstacles to optimal outcomes, particularly in patients with complex annular anatomy. We present the case of an 89-year-old female with severe mitral stenosis and MAC who developed acute hemolytic anemia following experimental TMVR using the Edwards SAPIEN S3 valve. This case serves as a platform to explore recent advances in TMVR, including novel device platforms, enhanced imaging modalities for pre-procedural planning, innovative deployment strategies, and emerging adjunctive techniques aimed at reducing complications. Through this case, we underscore persistent challenges and emphasize the importance of meticulous patient selection and vigilant follow-up. Despite substantial progress, TMVR in the setting of MAC remains high-risk, demanding continued innovation in valve design, refined patient stratification, and improved peri-procedural management to enhance outcomes and mitigate risks such as hemolysis. Full article